Chapter 7: Moving and positioning
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Evidence‐based approaches
Rationale
Patients will have reduced mobility in the immediate post‐operative phase and a multidisciplinary approach to care and rehabilitation is essential in achieving the best outcomes (Smith et al. [119]).
Frequent changes of position should be encouraged to prevent skin breakdown and contractures (Schreiber [115]). Early physiotherapy intervention is important to teach bed mobility as well as exercises to help prevent contractures, strengthen muscles and assist early mobilization.
Indications
Any patient who has had an upper or lower limb amputation. Moving and positioning a patient with an amputation may be required to:
- minimize pain and maximize comfort
- decrease oedema
- prevent pressure area damage
- promote wound healing.
Contraindications
There are no absolute contraindications, but specialist techniques and/or adaptations may be required as described in the following procedure guidelines.
Principles of care
The main goals of moving and positioning with regard to amputee management are to:
- prevent problems arising as a consequence of reduced mobility
- prevent compromise to the remaining, contralateral limb in lower limb amputees
- help to control residual limb oedema in order to assist wound healing
- help to decrease phantom (sensation in the part of the extremity that has been amputated) and residual limb pain
- prevent contractures and maintain joint range of movement and muscle strength in order to maximize function and rehabilitation potential (particularly if the patient's goal is prosthetic rehabilitation)
- assist the restoration of functional independence as soon as possible.
When assisting an amputee, it is important to consider the following points:
- Any level of amputation, either of an upper or lower limb, will alter the patient's centre of gravity, potentially resulting in decreased balance. This, in turn, will increase the risk of falls in this patient group.
- Body symmetry and posture will be altered, which can affect balance and may lead to poor postural habits that will hinder recovery and function.
The British Association of Chartered Physiotherapists in Amputee Rehabilitation (Smith et al. [119]) recommends a comprehensive assessment by key professionals to establish rehabilitation goals. This assessment should be carried out as soon as possible following the decision to amputate and there will need to be regular reviews. Nurses play a vital role at all stages providing technical and physical care, including wound care and assisting with personal hygiene (Schreiber [115]).
Where possible, care relating to positioning should commence during the pre‐operative stage. Patients should be encouraged to keep as mobile and independent as possible within their pain limits to reduce the effects of deconditioning. In the presence of pre‐operative pain, patients are frequently less able to mobilize and, as a result, may adopt positions of comfort that can lead to contractures. These positions are often maintained after amputation due to comfort and habit but are also due to changes in muscle balance (Devinuwara et al. [31], Ghazali et al. [39]). For example, transfemoral (above‐knee) amputees may adopt a flexed and abducted position of their residual limb due to an alteration in muscle balance and pain, but this can lead to contractures over time if not corrected. Contractures can profoundly affect the potential for prosthetic rehabilitation and overall function, so optimization of pain control and early correct positioning are paramount (Devinuwara et al. [31], Virani et al. [127]).
The general principles of care mentioned earlier in this chapter are all relevant to these patients. However, particular attention should be given to any possible balance issues for both upper limb and lower limb amputees. In the post‐operative phase, lower limb amputees should mobilize using the wheelchair provided for them unless the physiotherapist or occupational therapist has advised otherwise (Smith et al. [119]). This is because standing for long periods or hopping can:
- negatively influence residual limb oedema and wound healing
- increase the risk of falls and subsequently impede wound healing
- overtire a patient, particularly elderly patients and those who are physically deconditioned prior to the amputation
- encourage patients to adopt poor gait patterns due to excessive weight bearing on the remaining limb, leading to difficulty with prosthetic rehabilitation.
